Novel technology for the surgical treatment of cerebrovascular diseases

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1 SYⅣ- Utility of a novel surgical microscope laser light source and its application with integrated dual-image videoangiography (DIVA) Jun Sakuma, Taku Sato, Kyouichi Suzuki, Mudathir S Bakhit, Mazasumi Fujii, Tetsuo Sugano 3, Kiyoshi Saito Department of Neurosurgery, Fukushima Medical University Department of Neurosurgery, Fukushima Red Cross hospital 3 Kyoto office, Mitsubishi Electric Engineering Co., Ltd. ICG-VA is a valuable tool to evaluate vessel patency and aneurysm occlusion in cerebrovascular surgery. Although vessels are clearly shown as white over a black background, anatomic relationships of other structures are sometimes difficult to understand. We had developed a high-resolution intraoperative imaging system (dual-image videoangiography, DIVA to visualize light and near-infrared fluorescence images of ICG-VA simultaneously. Furthermore, we developed a new laser light source for surgical microscope as an alternative to the conventional Xenon light source. The new light source does not consist of the complex line spectrum as other light sources. The wavelength of the laser illumination includes only four bands, which are combined to produce a white color: 464 nm (blue), 53 nm (green), 640 nm (red), and 785 nm (near-infrared/nir). This spectrum was narrowed as much as possible to avoid the harmful high-energy ultraviolet spectrum. The NIR 785 nm wavelength is mainly for ICG excitation. A chromaticity analysis demonstrated that the laser light has a wider range of color coordinates and that it has a wider range of brightness. The color of the laser light source might feel unnatural to the operator's eye, due to a wider range of blue color in the laser light. Adjustment of the color temperature might be required to make it more natural. Together, the DIVA system and the laser light provide an excellent image for ICG-VA purposes. We'll present both system in more details followed by some clinical application cases.

2 SYⅣ- Force analysis and motion analysis for the risk management and the education of cerebrovascular surgery Taku Sugiyama, Garnette R Sutherland, Kiyohiro Houkin Department of Neurosurgery, Hokkaido University Hospital Department of Neurosurgery, University of Calgary Objective: As the apprenticeship model of surgical education evolves towards a more competency-based paradigm, there is need to devise sensitive and reliable methods for objective assessment of surgical skill. We utilized force analysis and motion analysis for the risk management and the education of cerebrovascular surgeries. Methods: A force sensing bipolar forceps was developed through installation of strain gauge sensors, and tool-tissue interaction force profiles were obtained from 6 neurosurgeries including two arteriovenous malformation (AVM) surgeries. We investigated the relationship between force profiles and incidence of intraoperative vascular injuries. On the basis of the hypothesis that the acceleration against the tissue was associated with the rough surgeon s motion, the acceleration against carotid plaques was investigated from 78 carotid endarterectomies (CEA) using video motion analysis software. Results: Force error analysis could discriminate the surgeon skill level with high accuracy. In AVM surgery, there was a strong association between the tool-tissue interaction forces and intraoperative vascular injuries. In CEA, there was an association between the acceleration against carotid plaque during surgery and postoperative ischemic stroke events. Conclusions: These quantifiable metrics may well detect and/or predict the occurrence of unexpected events during surgery as well as surgeon skill level, hence, would also be useful in the risk management and the education of neurosurgeries.

3 SYⅣ-3 Computational fluid dynamics for cerebral aneurysms in clinical settings Masato Shiba, Fujimaro Ishida, Hidenori Suzuki Department of Neurosurgery, Mie University Graduate School of Medicine Department of Neurosurgery, Mie Chuo Medical Center, National Hospital Organization Background: Computational fluid dynamics (CFD) is one of computational science, which complements between experiment and theory. It has been revealing that hemodynamics brings certain contribution to aneurysm pathology including initiation, growth and rupture using CFD. Methods: All patientspecific geometry models were generated using DICOM datasets of 3D CT angiography or 3D rotational angiography using commercially available software packages and numeral modeling was performed. The hemodynamic parameters such as WSS, shear rate (SR), oscillatory shear index (OSI), aneurysm formation indicator (AFI), gradient oscillatory number (GON) and residual flow volume (RFV) were calculated. These results were applied to various clinical settings including hyperplastic remodeling of aneurysm wall, flow alteration treatment of aneurysms, hemostatic pattern of ruptured cerebral aneurysms, and recurrence after coiling of cerebral aneurysms. Results: OSI was the most optimal hemodynamic parameter to predict hyperplastic lesions, which is valuable information in clipping an aneurysm with atherosclerotic wall. The hemostasis of ruptured cerebral aneurysms were divided into outside and inside patterns based on histopathological examination. These hemostatic patterns of ruptured cerebral aneurysms were characterized by AFI and GON. Low WSS and low SR are possible candidate hemodynamic parameters for flow alteration treatment of a complicated aneurysm. A novel hemodynamic parameter, RFV, which was calculated using CFD under porous media modeling, would predict the recurrence of coiled aneurysms. Conclusions: We are able to obtain unique information of cerebral aneurysms using CFD. For the accurate and detailed validation in a clinical setting, various hemodynamic parameters should be evaluated to assure possible therapeutic amelioration.

4 SYⅣ-4 Combination therapy for cerebrovascular disease in a hybrid operating room Koichi Arimura, Ataru Nishimura, Yojiro Akagi, Nobutaka Mukae, Yoichiro Kawamura, Nobuhiro Hata, Koji Iihara Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University Background: Rcently, it has been reported that combination therapy with endovascular and surgical procedures in hybrid operating room (hybrid OR) for complex is feasible. Materials and methods: We analyzed consecutive cases who underwent combination therapy with hybrid OR in our hospital from October 04 to December 07 (8 Aneurysms, 3 carotid artery stenosis, and dural arteriovenous fistula (DAVF)). Results: All procedures were performed successfully. We performed bypass surgery and internal trapping with endovascular treatment for all aneurysm cases. In 3 cases of carotid artery stenosis, we performed carotid artery stenting (CAS) with direct puncture of common carotid artery for cases and rescue stenting with carotid endarterectomy for case. Perioperative antiplatelet therapy were performed for all cases of unruptured aneurysms and carotid artery stenosis. In the case of DAVF, we performed transvenous embolization with direct puncture of superficial middle cerebral vein. Systemic full heparinization was performed during all endovascular procedures. There was no symptomatic hemorrhagic and ischemic complication. There was no neurological deterioration of modified Rankin scale at discharge except for the case of symptomatic hyperperfusion after CAS. Conclusion: Combination therapy with hybrid OR for complex cerebrovascular disease is safe and feasible.

5 SYⅣ-5 Internet of Things (IoT) for operation theater and Strategy Desk Tetsuya Goto, Kazuhiro Hongo, Yu Fujii, Jun Okamoto, Yoshihiro Muragaki, Go Mukumoto 3, Hideki Okuda 3 Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan Faculty of Advanced Techno-Surgery, Institute of Advanced Biomedical engineering and Science, Tokyo Women s Medical University, Tokyo, Japan 3 DESNSO Corporation, Kariya, Japan Smart Cyber Operation Theater (SCOT) is an idea of our clinical research for modifying the operation room by Internet of Things (IoT). Every surgical resource is connected by IoT technology OPeLiNK. OPeLiNK can store much information not only operative data, which includes operative video, location and working of surgical tools, location of microscope and operative table, and navigation data, but also perioperative data, which includes the anesthesic information, intraoperative patient s condition, intraoperative histopathological data, and so on. Stored information can be evaluated by other surgeons in the Strategy Desk, which is installed outside the operation room. The following procedures are determined by comprehensive communication between main surgeon in the operation room and Strategy Desk surgeons. In Shinshu University Hospital, we introduced OPeLiNK and Strategy Desk. Hospital computer systems such as Hospital In formation System (HIS) and Picture Archiving and Communication System (PACS) were connected to OPeLiNK. Strategy Desk was placed in the neurosurgical office and connected to the operation room by original light cable. After approval of the ethical committee of Shinshu University School of Medicine, we started clinical use of OPeLiNK since June 08. We will evaluate the efficacy of the SCOT, in which our clinical data by SCOT is compared with the previous our data without use of SCOT. This project is being carried out as a collaborative Japan Agency for Medical Research and Development (AMED) project since 04.

6 SYⅣ-6 Computer Aided Neurosurgical Care - No Longer the Future, but the Reality Chang Wan Oh, Tackeun Kim Seoul National University College of Medicine Seoul National University Bundang Hospital It is now the era of a new industrial revolution with growing computing capabilities involving every element in our life. Neurosurgery is no exception to these trends. The most important issue in medical field of the new era is definitely personalized medicine. From numerous data from various medical imaging, laboratory examinations, next generation sequencing and physical measurement data, we are trying to find valuable basis of neurosurgery in this era. Although numerous computational simulations have been performed in neuroscience, remarkable progress has been produced in cerebrovascular disease. However, due to the complexity of structure and boundary conditions, most of studies included relatively small sample numbers with selected patients. However, as growing the computational power, individualized assessment of pathogenesis and risks is possible in relatively short time. In the near future, real-time modeling and simulation will be implemented for providing personalized medicine. Another great tool of a new era is artificial intelligence powered by machine learning. Although it s been 60 years since the concept of artificial intelligence was introduced, recent advancement of GPU parallel computing leads explosive growing. According to tremendous accumulation of health-related data, it is worth a challenge to try to predict disease, prognosis and proper treatments. In this context, I would like to present about application of computational simulation and machine learning in neurosurgical field.